Factor structure of posttraumatic stress disorder (PTSD) in persons with serious mental illness.

BACKGROUND: Trauma and posttraumatic stress disorder (PTSD) are common among individuals with serious mental illness (SMI; e.g., schizophrenia, schizoaffective disorder, bipolar disorder, treatment refractory major depressive disorder), with resultant functional impairment. Previous studies have not evaluated the factor structure of the PTSD Checklist (PCL) among persons with SMI. AIMS: This study evaluated the factor structure of the PCL in two large SMI samples from public mental health treatment sectors screened for PTSD using the PCL. METHODS: Four different models of PTSD were tested using confirmatory factor analyses. RESULTS: Results indicated that the DSM-5 4-factor model (intrusion, avoidance, numbing, and hyperarousal) had the best fit. Further, the DSM-5 4-factor model demonstrated measurement invariance. CONCLUSIONS: Results supported the suitability of the DSM-5 4-factor model of PTSD among people with SMI.

Post-Traumatic Cognitions Inventory (PTCI): psychometric properties in clients with serious mental illness and co-occurring PTSD.

BACKGROUND: People with post-traumatic stress disorder (PTSD) exhibit negative cognitions, predictive of PTSD severity. The Post-Traumatic Cognitions Inventory (PTCI) is a widely used instrument measuring trauma-related cognitions and beliefs with three subscales: negative thoughts of self (SELF), negative cognitions about the world (WORLD), and self-blame (BLAME). AIMS: The current study attempted to validate the use of the PTCI in people with serious mental illness (SMI), who have greater exposure to trauma and elevated rates of PTSD, using confirmatory factor analysis (CFA) and examining convergent and divergent correlations with relevant constructs. METHOD: Participants were 432 individuals with SMI and co-occurring PTSD diagnosis based on the Clinician Administered PTSD Scale, who completed PTCI and other clinical ratings. RESULTS: CFAs provided adequate support for Foa's three-factor model (SELF, WORLD, BLAME), and adequate support for Sexton's four-factor model that also included a COPE subscale. Both models achieved measurement invariance at configural, metric and scalar levels for three diagnostic groups: schizophrenia, bipolar and major depression, as well as for ethnicity (White vs Black), and gender (male vs female). Validity of both models was supported by significant correlations between PTCI subscales, and self-reported and clinician assessed PTSD symptoms and associated symptoms. CONCLUSIONS: Findings provide support for the psychometric properties of the PTCI and the conceptualization of Sexton's four-factor and Foa's three-factor models of PTCI among individuals diagnosed with SMI (Foa et al., ).

Understanding explanatory mechanisms for racial and ethnic differences in mental health stigma: the role of vertical individualism and right-wing authoritarianism.

BACKGROUND: Mental health (MH) stigma is pervasive worldwide. Culturally sensitive stigma reduction programs are needed to reduce MH stigma. AIMS: To determine racial/ethnic and cultural predictors of stigma. METHOD: The current study examined the relationship between cultural orientation (individualism-collectivism beliefs), race/ethnicity, and political beliefs (right-wing authoritarianism [RWA]). Participants (N = 951) from the United States completed an online survey for this cross-sectional study. RESULTS: Findings indicated that vertical individualism is a consistent, though modest, predictor of multiple dimensions of MH stigma, controlling for other predictors. Contrary to what was hypothesized, vertical individualism did not mediate the relationship between Asian-American race/ethnicity and MH stigma, but was found to mediate the relationship between RWA and stigma. A novel finding was that RWA mediated the relationship between African-American race/ethnicity and multiple MH stigma domains. CONCLUSIONS: Findings therefore indicate that the endorsement of authoritarian views, rather than vertical-individualism (which advances the idea that everyone is in competition), is the primary mechanism of MH stigma differences between African-Americans and individuals from other racial/ethnic groups. A major implication from this study is that efforts to address MH stigma among specific cultural groups should incorporate a sensitivity to the role of both RWA and vertical individualism in facilitating stigma.

The impact of illness identity on recovery from severe mental illness: A test of the model.

OBJECTIVE: The Illness Identity model posits that self-stigma reduces hope and self-esteem among persons with severe mental illnesses, impacting a range of outcomes. The "insight paradox" anticipates that the negative effects of self-stigma are amplified by insight. This study tested these predictions using both cluster and path analyses. METHOD: A total of 117 participants meeting the criteria for schizophrenia-spectrum disorders completed measures of self-stigma, self-esteem, hopelessness, insight, social functioning, coping, and symptoms. RESULTS: Cluster analysis supported the insight paradox; persons with low self-stigma/high insight had fewer psychiatric symptoms and better interpersonal functioning than persons with high self-stigma/low insight. Path analysis did not support the insight paradox, but indicated that self-stigma and insight impact different outcomes. DISCUSSION: Findings suggest that support for the predictions of the Illness Identity model and insight paradox are supported may depend on analytic method. CONCLUSIONS: Finding suggest that the benefits of self-stigma reduction may be constrained by insight.

A randomized-controlled trial of treatment for self-stigma among persons diagnosed with schizophrenia-spectrum disorders.

PURPOSE: A substantial body of research indicates that self-stigma is associated with poorer outcomes related to recovery among people with severe mental illnesses. Narrative Enhancement and Cognitive Therapy (NECT) is a structured, group-based approach which targets the effects of self-stigma. A randomized-controlled trial was conducted to examine the efficacy of NECT. METHODS: One hundred and seventy persons, recruited from both outpatient and comprehensive treatment settings, meeting criteria for schizophrenia-spectrum disorders and moderate-to-elevated self-stigma, were randomly assigned to NECT or supportive group therapy and assessed at four time points over the course of nearly a year. Participants completed measures of self-stigma, hope, self-esteem, functioning, psychiatric symptoms, coping with symptoms, and narrative insight. RESULTS: Analyses indicated that NECT participants in outpatient sites improved significantly more over time in self-stigma compared to supportive group therapy participants in outpatient sites, while NECT participants in comprehensive (including day treatment and psychiatric rehabilitation program) sites improved significantly more in hopelessness and narrative insight than other participants. NECT participants as a group showed decreases in the social withdrawal component of self-stigma, decreased in their use of avoidant coping strategies, and were more engaged in treatment than supportive group therapy participants. There was no evidence for effects of NECT on social functioning or psychiatric symptoms. CONCLUSIONS: Findings suggest that NECT primarily impacts self-stigma and related outcomes, and that the degree of its effects is partially dependent on the treatment context in which it is offered.

Community Protection versus Individual Healing: Two Traditions in Community Mental Health.

This article identifies two major traditions that drive the mandate for a community mental health care system-community protection and individual healing. It discusses the historical antecedents of these two traditions and how these traditions relate to different visions of what the "common good" means. It then discusses how they both operate in the current US-based system, creating inherent conflicts and tensions, and gives specific examples from the personal and professional experiences of the authors. The article proposes ways to reduce the tension and discusses what sacrifices and compromises this resolution would entail for the US community mental health system. Copyright © 2017 John Wiley & Sons, Ltd.

Insight among people with severe mental illness, co-occurring PTSD and elevated psychotic symptoms: Correlates and relationship to treatment participation.

BACKGROUND: There is a dearth of research on what factors are predictive of insight among people with severe mental illness and co-occurring PTSD. METHOD: Data were drawn from 146 participants with severe mental illness, co-occurring PTSD and elevated psychotic symptoms participating in a randomized controlled trial comparing two interventions for PTSD among people with severe mental illness. We examined the clinical and demographic correlates of insight at baseline, the relationship between baseline insight and treatment participation, the relationship between treatment participation and post-treatment insight, and the relationship between change in insight and change in other clinical variables. RESULTS: Impaired insight was relatively common, with roughly half the sample demonstrating mild or moderate impairment at baseline. Baseline insight was associated with fewer psychotic and disorganized symptoms, and greater emotional discomfort and PTSD knowledge, but was not associated with negative symptoms, PTSD symptoms, depression/anxiety, or treatment participation. Participation in PTSD treatment was associated with increased insight at post-treatment. Improved insight was associated with improvements in disorganization and negative symptoms, but not with knowledge of PTSD or positive symptoms. DISCUSSION: The findings suggest that engagement in treatment that includes educating people about PTSD may lead to improvements in insight and related improvements in other psychiatric symptoms.

The trees and the forest: mixed methods in the assessment of recovery based interventions' processes and outcomes in mental health.

BACKGROUND: Recent developments in mental health have emphasized recovery as an outcome for people with serious mental illness (SMI). Accordingly, several studies have attempted to evaluate the process and outcome of recovery-oriented psychosocial interventions. AIMS: To review and discuss quantitative and qualitative findings from previous efforts to study the impact of five recovery-oriented interventions: Illness Management and Recovery (IMR), Narrative Enhancement and Cognitive Therapy (NECT), Supported Employment (SE), Supported Socialization (SS), and Family Psychoeducation. METHODS: Reviewing the literature on studies that examine the effectiveness of these interventions by using both quantitative and qualitative approach. RESULTS: Qualitative findings in these studies augment quantitative findings and at times draw attention to unexpected findings and uniquely illuminate the effects of these interventions on self-reflective processes. CONCLUSIONS: There is a need for further exploration of how mixed-methods can be implemented to explore recovery-oriented outcomes. Critical questions regarding the implications of qualitative findings are posed.

Evaluation of cognitive restructuring for post-traumatic stress disorder in people with severe mental illness.

BACKGROUND: A cognitive-behavioural therapy (CBT) programme designed for post-traumatic stress disorder (PTSD) in people with severe mental illness, including breathing retraining, education and cognitive restructuring, was shown to be more effective than usual services. AIMS: To evaluate the incremental benefit of adding cognitive restructuring to the breathing retraining and education components of the CBT programme (trial registration: clinicaltrials.gov identifier: NCT00494650). METHOD: In all, 201 people with severe mental illness and PTSD were randomised to 12- to 16-session CBT or a 3-session brief treatment programme (breathing retraining and education). The primary outcome was PTSD symptom severity. Secondary outcomes were PTSD diagnosis, other symptoms, functioning and quality of life. RESULTS: There was greater improvement in PTSD symptoms and functioning in the CBT group than in the brief treatment group, with both groups improving on other outcomes and effects maintained 1-year post-treatment. CONCLUSIONS: Cognitive restructuring has a significant impact beyond breathing retraining and education in the CBT programme, reducing PTSD symptoms and improving functioning in people with severe mental illness.

Between self-clarity and recovery in schizophrenia: reducing the self-stigma and finding meaning.

Although there are extensive theoretical reviews regarding the self-experience among persons with schizophrenia, there is limited research that addresses the implications of self-clarity on the recovery of persons with schizophrenia while exploring the role of possible mediators within this process. Accordingly, the current study explored the relationship between self-clarity and recovery while examining the possible mediating role of self-stigma and sense of meaning in life. 80 persons with schizophrenia or schizoaffective disorder were administered four scales: self-concept clarity, self-stigma, meaning in life, and recovery. Results confirmed the hypothesized model in which self-clarity affects self-stigma, self-stigma affects meaning in life, and meaning in life affects recovery. No direct relationship was uncovered between self-clarity and recovery. Implications of the current study for future research and clinical practice are discussed with the emphasis on the importance of the self-experience with regard to the process of recovery.

Narrative enhancement and cognitive therapy (NECT) effectiveness: a quasi-experimental study.

OBJECTIVE: Accumulated evidence suggests that approximately one third of people with a serious mental illness (SMI) experience elevated self-stigma. Narrative enhancement and cognitive therapy (NECT) is a structured group-based intervention aimed to reduce self-stigma. The current study aims to examine the effectiveness of NECT. A quasi-experimental design. DESIGN: Baseline and follow-up data were collected and outcomes were compared between 63 persons with SMI who participated in NECT and 56 persons who received treatment as usual. RESULTS: The NECT treatment group showed significant (p < .05) reductions in self-stigma and increases in self-esteem, quality of life, and Hope-Agency scores between pre- and posttreatment assessments, compared with the control group. CONCLUSIONS: The current results provide preliminary support for the use of NECT as an effective treatment to reduce self-stigma and its implications for treatment and practice are discussed.

Public mental health clients with severe mental illness and probable posttraumatic stress disorder: trauma exposure and correlates of symptom severity.

Individuals with severe mental illness (SMI) are at greatly increased risk for trauma exposure and for the development of posttraumatic stress disorder (PTSD). This study reports findings from a large, comprehensive screening of trauma and PTSD symptoms among public mental health clients in a statewide community mental health system. In 851 individuals with SMI and probable PTSD, childhood sexual abuse was the most commonly endorsed index trauma, followed closely by the sudden death of a loved one. Participants had typically experienced an average of 7 types of traumatic events in their lifetime. The number of types of traumatic events experienced and Hispanic ethnicity were significantly associated with PTSD symptom severity. Clients reported experiencing PTSD in relation to events that occurred on average 20 years earlier, suggesting the clinical need to address trauma and loss throughout the lifespan, including their prolonged after-effects.

Who is afraid of Hermy and Jimmy? Relating to and normalizing psychosis through theater.

OBJECTIVE: Psychotic experiences, such as hearing voices that others do not hear, being afraid of threats that others do not perceive, or believing in ideas that others find implausible can be confusing for those who face them and challenging to relate to for those who do not, leading to alienation and social exclusion. The objective of this article is to discuss how immersion in theater can enhance our understanding of human nature and facilitate a social environment that supports the recovery of individuals with psychosis. METHODS: Drawing on theories of the psychology of art and narrative psychology, this conceptual article discusses a theatrical production, a play, titled "Voices," created by a person with lived experience of voice hearing. We apply Semenov's model of art as a social psychological system as a guiding framework to focus on the roles of the art product, artist-author, artist-performer, and recipient. RESULTS: Theater is a uniquely reciprocal art form where actors and spectators share emotional, intellectual, and cathartic experiences, which could foster interpersonal connection, personal growth, and empathy. This article brings new perspective on how theater can elucidate psychotic experiences, encourage dialogue about these experiences, and facilitate social integration and recovery of individuals living with psychosis. CONCLUSION AND IMPLICATIONS FOR PRACTICE: Theater can promote social change, making space for a wider range of perspectives in society. Engaging individuals with lived experiences of psychosis in theatrical productions could lead to new insights about and acceptance of psychotic experiences, both for these individuals and for society at large. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Diagnostic profiles and trauma history among treatment-seeking young adults with positive post-traumatic stress disorder screens: Findings and implications for public mental health care.

OBJECTIVES: This study examined diagnostic profiles and trauma history among treatment-seeking young adults with positive PTSD screens in public mental health care. METHODS: Screening for trauma history and PTSD symptoms was implemented in a community mental health service system. 266 treatment-seeking young adults (aged 18-35) endorsed trauma exposure with a score of at least 45 on the DSM-IV PTSD Checklist, indicating probable PTSD. RESULTS: Young adults with positive PTSD screens were predominantly female, minority, and diagnosed with mood disorders. Of those with positive screens, only 15% had a chart diagnosis of PTSD; 17.3% (ages 18-24) versus 14.1% (ages 25-35). Variables significantly associated with a decreased likelihood of PTSD detection included a diagnosis of schizophrenia or bipolar disorder, exposure to fewer types of traumatic events, male gender, and white race. CONCLUSION: Routine PTSD screening for young adults receiving public mental health care should be prioritized to address long-term impacts of trauma.

Relationships between stereotyped beliefs about mental illness, discrimination experiences, and distressed mood over 1 year among persons with schizophrenia enrolled in rehabilitation.

PURPOSE: Research suggests stereotype endorsement or self-stigma serves as a barrier to functioning and well-being among persons with schizophrenia. Little is known about how stable self-stigma is and whether it is linked over time with related constructs such as discrimination experiences and psychological distress. METHODS: Stereotype endorsement and discrimination experiences were assessed using the Internalized Stigma of Mental Illness Scale and psychological distress was assessed using the Emotional Discomfort component of the Positive and Negative Syndrome Scale, at three points in time across 1 year. RESULTS: Path analyses indicated that the constructs of stereotype endorsement and discrimination experiences are stable over periods of 5-7 months and may fluctuate over 12 months. Further, the constructs of stereotype endorsement and discrimination experiences were related to one another concurrently, but analyses failed to detect a relationship over time. Neither construct was related to psychological distress over time. CONCLUSIONS: Self-stigma is a stable construct in the short term, and is distinct from related constructs such as discrimination experiences and psychological distress.

I feel frozen: Client perceptions of how posttraumatic stress disorder impacts employment.

Objective: There is evidence that posttraumatic stress disorder (PTSD) is a hidden barrier to employment among individuals with serious mental illnesses (SMI) among whom PTSD is highly prevalent. This study aimed to explore how PTSD interferes with achieving employment outcomes among persons with SMI. Methods: Participants included 119 individuals with SMI and co-occurring PTSD receiving Supported Employment services. Responses to the question, "In what ways are PTSD symptoms interfering with your work during the past month?" were analyzed. Results: Six themes emerged: (a) I don't like being around people, (b) I feel frozen and unable to get started, (c) troubling negative affect, (d) mind is scattered and all over the place, (e) feeling fatigued all the time, and (f) flashbacks and triggers can happen whenever. Conclusions and Implications for Practice: Findings provide insight into how PTSD symptoms impact work outcomes and suggest that there is a need for Supported Employment providers to screen clients for trauma exposure to identify those in need of additional support in order to improve work outcomes. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Psychometric properties of post-traumatic stress disorder (PTSD) checklist for DSM-5 in persons with serious mental illness.

BACKGROUND: PCL-5 is a self-report measure consisting of 20 items that are used to assess the symptoms of Post-Traumatic Stress Disorder (PTSD) according to the DSM-5. OBJECTIVE: This study evaluated the factor structure of the Post-Traumatic Stress Disorder (PTSD) Checklist for DSM-5 (PCL-5) in people with serious mental illness. METHOD: The sample in Study 1 included 536 participants with serious mental illness who were receiving supported employment services through community mental health agencies or supported housing programmes. Confirmatory factor analysis assessed the fit of six different models of PTSD. RESULTS: Results indicated that Armour's Hybrid 7-factor model composed of re-experiencing, avoidance, dysphoria, dysphoric arousal, anxious arousal, negative affect, anhedonia, and externalizing behaviours demonstrated the best fit. Study 2 found support for convergent validity for PCL-5 among 132 participants who met criteria for PTSD. CONCLUSION: Findings provide support for the psychometric properties of the PCL-5 and the conceptualization of the 7-factor hybrid model and the 4-factor DSM-5 model of PTSD among persons living with serious mental illness.

Antecedentes:PCL-5 es una medida de autoinforme que consta de 20 ítems que se utilizan para evaluar los síntomas del TEPT de acuerdo al DSM-5.Objetivo:Este estudio evaluó la estructura factorial de la Lista de verificación de Trastorno de Estrés Postraumático (TEPT) para DSM-5 (PCL-5) en personas con enfermedades mentales graves.Método:La muestra del Estudio 1 incluyó a 536 participantes con enfermedad mental grave que estaban recibiendo servicios de empleo subvencionado a través de agencias comunitarias de salud mental o programas de vivienda subvencionados. El análisis factorial confirmatorio evaluó el ajuste de seis modelos diferentes de TEPT.Resultados:Los resultados indicaron que el modelo híbrido de 7 factores de Armour - compuesto de reexperimentación, evitación, disforia, excitación disfórica, excitación ansiosa, afecto negativo, anhedonia y conductas de externalización - demostró el mejor ajuste. El estudio 2 encontró sustento para la validez convergente de PCL-5 entre 132 participantes que cumplieron con los criterios para TEPT.Conclusión:Los hallazgos respaldan las propiedades psicométricas del PCL-5 y la conceptualización del modelo híbrido de 7 factores y el modelo DSM-5 de 4 factores de TEPT entre personas que viven con una enfermedad mentales graves.

Predictors of undocumented PTSD in persons using public mental health services.

Individuals diagnosed with serious mental illness (SMI) have greater trauma exposure and are at increased risk for posttraumatic stress disorder (PTSD). However, PTSD is rarely documented in their clinical records. This study investigated the predictors of PTSD documentation among 776 clients with SMI receiving public mental health services, who had probable PTSD as indicated by a PTSD Checklist score of at least 45. Only 5.3% of clients had PTSD listed as a primary diagnosis, and 8.4% had PTSD as a secondary diagnosis, with a total 13.7% documentation rate. PTSD documentation rate was highest for clients with major depression (18.8%) compared to those with schizophrenia (4.1%) or bipolar disorder (6.3%). Factors that predicted a lower likelihood of having a chart diagnosis of PTSD included being diagnosed with schizophrenia/schizoaffective disorder or bipolar disorder. Factors that predicted a higher likelihood of having a chart diagnosis of PTSD included being of non-white race, being female, and experiencing eight or more types of traumatic events. Findings highlight the need for PTSD screening and trauma informed care for clients with SMI receiving public mental health services.

An examination of time-use among adults diagnosed with severe mental illnesses using daily interviews.

OBJECTIVE: The authors examined clinical, demographic and programmatic predictors of average time-use during weekdays and weekends. METHODS: Mental health consumers (N = 22) participating in day treatment (DT) and assertive community treatment (ACT) programs first completed measures of symptoms and substance use, and then completed daily interviews on time-use for up to 20 days. RESULTS: Consumers who were participating in DT, as opposed to ACT, spent more weekday time in productive activity, but only when treatment was considered productive activity. DT participants also reported more weekend productive time-use. Clinical and demographic variables did not predict productive time-use, with the exception of negative symptoms (which predicted less) and African-American ethnicity (which predicted more). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Findings are consistent with previous studies indicating that many mental health consumers spend considerable amounts of time involved in sleep and passive leisure. However, structural factors, rather than symptoms, may be the greatest determinants of productive time-use. Rehabilitation interventions may need to be tailored to increase such opportunities for productive time-use.

Where are all the psychologists? A review of factors impacting the underrepresentation of psychology in work with serious mental illness.

Over the last few decades, clinical psychologists have played a key role in the development of empirically-validated psychosocial interventions for those with serious mental illness (SMI). However, in contrast to these substantial contributions, clinical psychologists in the United States are grossly underrepresented in treatment provision with this population (Roe, Yanos, & Lysaker, 2006; Rollins & Bond, 2001). This review aims to highlight various factors contributing to the establishment and perpetuation of this underrepresentation. First, we highlight systemic factors (e.g., the emergence of managed care) through an examination of the evolving role of the clinical psychologist. Next, we review training-based factors (e.g., limitations to SMI specific training) through a review of training in clinical psychology. Through an examination of training factors, the role of mental health stigma amongst clinicians toward individuals with SMI is identified as a potential perpetuating factor of this underrepresentation. Factors associated with clinician stigma are then reviewed and the relationship between clinical training and clinician stigma is considered. Lastly, important future directions to further investigate and address this underrepresentation are suggested - namely, investigating factors (training and individual) that may impact clinical psychology doctoral students' attitudes toward those with SMI.